I don't have any clinical information on this case unfortunately but it looks like an interesting ECG :-)
- Overall rate 60 bpm
- Irregular - likely regularly irregular
- Pattern of 2 sinus complexes followed by 2 ventricular complexes
- Sinus complexes
- PR - Normal ( 160ms)
- QRS - Prolonged (120ms)
- QT - 400ms (QTc Bazette ~ 430 ms)
- Ventricular complexes
- QRS - Prolonged (180ms)
- QT - 480ms
- ST Elevation V2-4 of sinus complexes discordant to QRS
- Discordant ST & T wave changes of ventricular complexes
- Notching in terminal portion of 1st ventricular complexes
- Best seen in lead II
- Corresponds to atrial activity at a rate of 55 bpm
- Regularly irregular atrial activity in pattern of 3 complexes then pause
- Poor R wave progression
- Sinus rhythm
- Intraventricular conduction delay
- Regular coupled ventricular ectopics
- Electrolyte / acid base disturbance
- esp. digoxin
- Environmental e.g. hypothermia
For those planning to sit the ACEM Fellowship, or any of our other interested readers.
I don't know anything about the real case so I've made up the clinical details for this question.
A 76 yr old female presents to your ED following a collapse at home.
She complains of feeling dizzy and lethargic for the last 2 days.
She has a history of IHD, CCF, and hypertension.
She is on multiple medications but can not recall them.
Observations: BP 85/45 RR 16 Sats 95% RA GCS 14 (M=6 V=5 E=3)
a) Describe & interpret the ECG (50%)
b) Outline your management (50%)
I won't directly be answering our VAQ corner questions on the blog, unless it's a 100% describe and interpret. These questions are designed to give people the oppurtunity to think about the ECG with some clinical context, especially when I don't have a real case to attach to, and also to provide a chance to do some VAQ practice.
If people would like to submit some answers I will happily added them to our posts, just email them to me here.
References / Further Reading
Life in the Fast Lane
- PVC's here
- Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.